Claims Auditor

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Full Time Professional Miami, FL, US

We are seeking a Claims Auditor to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

About the Role:

The Claims Auditor plays an essential role in ensuring the accuracy, compliance, and integrity of health care claims within the organization. This position involves conducting thorough audits of submitted claims to verify adherence to regulatory standards, contractual obligations, and internal policies. The Claims Auditor will identify discrepancies, potential fraud, and areas for process improvement, thereby safeguarding the organization's financial health and reputation.

By collaborating with claims processors, healthcare providers, and compliance teams, the auditor helps to streamline claims management and reduce errors. Ultimately, this role supports the delivery of efficient and ethical services by maintaining transparent and accountable claims operations.

Minimum Qualifications:

• Bachelor’s degree in Health Administration, or a related field.
• At least 2 years of experience in claims auditing, health care compliance, or a similar role within the health care industry.
• Strong knowledge of health care claims processes, insurance billing, and regulatory requirements such as HIPAA and CMS guidelines.
• Proficiency in audit software and Microsoft Office Suite, particularly Excel for data analysis.
• Relevant experience may substitute for the educational requirement on a year-for-year basis.

Preferred Qualifications:

• Master’s degree in Health Administration, or a related field.
• Certification such as Certified Internal Auditor (CIA), Certified Professional Coder (CPC), or Certified Healthcare Auditor (CHA).
• Experience with claims management software.
• Familiarity with fraud detection techniques and health care fraud prevention programs.
• Demonstrated ability to lead audit projects or mentor junior auditors.

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Conduct detailed audits of healthcare claims to ensure accuracy, compliance with regulations, and adherence to organizational policies.
• Analyze claim data and documentation to identify errors, inconsistencies, or potential fraud.
• Prepare comprehensive audit reports with findings, recommendations, and corrective actions for management and stakeholders.
• Collaborate with claims teams and healthcare providers to resolve discrepancies and drive process improvements.
• Stay updated on healthcare regulations and industry best practices, while supporting internal and external audits with relevant documentation and insights.